Does Abortion Access Protect Women's Health?

Jeanne E. Head, a retired labour and delivery nurse, is vice president for international affairs and UN representative for the National Right to Life Committee. Laura Hussey is a Ph.D. student and research assistant for the National Right to Life Committee.

Just as abortion continues to stir a storm of acrimony in the United States, controversy rages around the world over the procedure's legalization in the many countries that still prohibit or sharply limit it. The chief justification for making abortion legal is reducing maternal mortality. Yet what's often overlooked in the debate is that the main factor that has dramatically diminished abortion-related fatalities since the 1930s and '40s until today is not legalizing the procedure so much as improving the overall quality of national health- care systems.

Organizations such as the UN's World Health Organization (WHO) report 40-50 million annual abortions worldwide with 70,000 abortion-related maternal deaths. Scanty data, however, make an accurate assessment of the status of abortion and abortion laws throughout the world a daunting, virtually impossible task. WHO's estimates are largely constructed by statistical estimation, based on meager data and poorly supported assumptions.

The group nonetheless frequently repeats these figures in the interest of expanding the legality of abortion, as do the United Nations Fund for Population Activities (UNFPA) and other UN bodies. So do their nongovernmental partners, whose ranks include such abortion advocates as the International Planned Parenthood Federation (IPPF), the International Women's Health Coalition (IWHC, which has published a manual for increasing access to abortion), and the Center for Reproductive Rights (CRR, formerly known as the Center for Reproductive Law and Policy).

Unfortunately, untrustworthy statistics lead to misidentifying the real causes of maternal mortality in the developing world. They also result in channeling valuable resources away from improving general and maternal health care and the overall health status of women, which, according to WHO's 1991 Maternal Mortality: A Global Fact Book, sharply decreased maternal mortality in the developed world from 1941 to 1951, long before legalization of abortion.

Although it was not a new idea, the move to make abortion a global, fundamental human right began in earnest with the 1994 International Conference on Population and Development (ICPD) in Cairo. After much controversy and compromise, participating countries ultimately stopped short of any outright call for a worldwide legal right to abortion but agreed on language involving calls to advance reproductive rights and reproductive health services, decrease the "need" for abortion, and eliminate "unsafe abortion." While these goals sound apolitical, abortion advocates in fact view them as synonyms for the broad legalization of abortion. IWHC, for example, recently challenged fellow abortion proponents to state their mission more boldly, "to move beyond the rhetoric of 'prevention and management of unsafe abortion' to argue that access to safe abortion is the most direct way to eliminate unsafe abortion."

STATUS OF WORLD ABORTION LAWS

In preparation for the Cairo ICPD, the UN Population Division in 1994 published Abortion Policies: A Global Review to catalog the world's abortion laws. It updated this in 1999, before the five-year review of the Cairo conference. In these volumes, the Population Division shared some of its difficulties in gathering this information. For starters, several countries had not codified their abortion laws, leaving decisions about its legality to common law or religious law. Researchers struggled to obtain legal documents from many developing countries.

Even where abortion law was codified, researchers found it difficult to know where in a country's code to look for the law. They found that abortion policies were not always uniform throughout a nation, especially if the state had a federal structure. Information on the law was not always widely disseminated. Even in the case of actual, written law, the problem remained that abortion laws are often subject to a wide range of interpretation and enforcement.

Further, as we observed in our own research, even reports on the world's abortion laws diverge, sometimes substantially. For example, in its 1999 report, the Population Division reported that 120 countries permitted abortion to preserve the mother's mental health, while in a 2003 report, CRR listed only 88 countries with a mental health exception. One should therefore hesitate to accept any single report as entirely factually correct.

That said, according to the Population Division, approximately three- quarters of UN member states (140 of 192) provide some restriction on abortion as of 1999. All countries studied permit abortion to save the life of the mother, with the exception of 3 in which a defense of "necessity" may nevertheless allow the abortion. Including these 3, 65 countries allow abortion only to save the mother's life. Fifty-two permit abortion on request, for any reason. Among the remaining 75 nations, in addition to allowing abortion to save the mother's life, 1 allows the procedure for the mother's physical health, and 3 add an exception in cases of rape or incest. Thirty-seven countries permit abortion to preserve the mother's life, physical health, or mental health only, and 7 expand the list with rape or incest. Twelve add fetal impairment to all the latter, and 6 add economic and social reasons to the physical or mental health and rape or incest exceptions. Nine countries combine these exceptions differently.

Within these categories, there is much variation in interpretation, implementation, and limitations pertaining to such elements as spousal or parental consent and the period of gestation. For example, CRR reports that most countries, including those that allow abortion on demand, provide some gestational limits (8--24 weeks) on abortion. They do not include the United States here, for the Supreme Court's application of its broadly defined health exception to the third trimester of pregnancy effectively allows abortion on request throughout pregnancy.

In its draft release of World Population Monitoring 2002, the Population Division remarks, "The past decade witnessed significant developments in abortion trends and laws." However, when one compares the Population Division's 1994 report and its accompanying summary chart to its 1999 edition, a detailed reading reveals that very few countries have actually changed their abortion laws.

The Population Division's summaries indicate that from 1994 to 1999, 53 countries expanded the conditions under which abortion was legal, 11 restricted those conditions, and 1 both added and subtracted conditions. The report's text, however, identifies a legal or regulatory change to abortion's status in only a small fraction of these countries. The policy chart's footnotes explained more. For many countries that appeared to have changed their laws, researchers had merely recoded as the country's 1999 policy those same policy interpretations that had been footnoted in 1994. For example, while 25 countries appeared to have added a mental health exception between 1994 and 1999, most of the changes could be accounted for by a decision to begin interpreting a "health" exception to include mental health, as is done in the United States. This, too, could explain the disparity between the Population Division and CRR reports.

The mental health exception is a special concern because it has become a legal wedge that essentially allows abortion on demand. Much of the Population Division's misinterpretation involved Central American, South American, and Muslim countries that have persistently resisted calls to broadly legalize abortion. After obtaining and examining the abortion laws of several Latin American countries and interviewing knowledgeable individuals from these countries, we learned that, indeed, none of the laws we studied have exceptions for mental health. Argentina reiterated its legal protection of fetal life from conception as recently as 1997; like many other Latin American countries, it strictly enforces its health exception.

HOW DO ABORTION LAWS CHANGE?

Some countries actually changed their laws after 1994, particularly when America's so-called Mexico City policy was not in effect (1993--2000). (Under this policy, only family planning organizations that do not perform or promote abortion or work to change foreign countries' abortion laws can receive U.S. "population assistance" funds for their activities.) In many of these countries, U.S.-based and other foreign nongovernmental organizations, such as the U.S. Agency for International Development (USAID) and family-planning funds recipients IPPF and PPFA, played a major role. This is one reason abortion advocates so vigorously protested President George W. Bush's reinstatement of the Mexico City policy in January 2001.

The U.S.-based CRR filed a lawsuit in 2001 against Bush, challenging the Mexico City policy. In its complaint, CRR details its strategy of working through foreign NGOs and using UN conferences and treaties to bypass national legislatures and establish "a right to abortion in the United States and every country on earth." As a consequence, CRR lists Guyana, Albania, Burkina Faso, South Africa, and Cambodia among the several countries that liberalized their abortion laws in the wake of the two major UN conferences at which the abortion issue loomed large: the 1994 Cairo ICPD and the 1995 Beijing Fourth World Conference on Women. As of 2001, CRR reported that it had ongoing specific projects in 23 countries. Several nations in this group have recently liberalized their abortions laws.

CRR boasts that many of these changes took place with the help of foreign NGOs receiving USAID funds. South Africa's law, which was changed in 1996 over the objections of a majority of the population and in the absence of almost one-quarter of the legislature, is described in Abortion Policies: A Global Review as "the most liberal in Africa, and, indeed, the world." More recently, CRR applauds its part in the government of Nepal's 2002 decision to legalize abortion on request through 12 weeks of pregnancy--and beyond when certain conditions are present. On its Web site, PPFA International similarly credits several of its partners in Nepal.

NUMBERS OF ABORTIONS

Earlier we mentioned the most prevalent argument made by abortion advocates to convince countries to liberalize their abortion laws--that vast numbers of women are undergoing and dying from "unsafe" abortions in countries where abortion is not broadly legal.

We put the word unsafe in quotes because WHO actually defines unsafe as "illegal." In its 1998 report Unsafe Abortion, the organization says, "For the purpose of these tabulations, unsafe abortion has been defined as an 'abortion not provided through approved facilities and/or persons.' " WHO continues: "What constitutes 'approved facilities and/or persons' will vary according to the legal and medical standards of each country," but at the same time it admits that "the legality or illegality of the services may not be the defining factor of their safety."

Even if we were able to identify those types abortions that are dangerous, we simply do not have the data to count them. Many developing countries lack even basic birth and death registration systems. We do, however, have "estimates," in the roughest sense of the word. In Unsafe Abortion, WHO estimates that 20 million "unsafe" abortions are performed every year. Planned Parenthood's research affiliate, the Alan Guttmacher Institute (AGI), estimates 26 million legal abortions worldwide and thus tags the annual total at 46 million in its 1999 report, Sharing Responsibility. Both reports admit the roughness of these figures.

In World Population Monitoring 2002, the UN Population Division calls these estimates "quite speculative since hard data are missing for the large majority of countries." Further, even in those countries in which some abortions are legal, statistics were available for just 45 countries and in only half of them were the data believed to be "reasonably complete." This means that worldwide abortion estimates are largely constructed by statistical estimation, based on a very meager amount of actual data. WHO's report shows that most data on developing countries come from the following sources:

Counts of women admitted to hospitals for abortion complications.

Surveys asking women about their abortion history.

Papers written by NGOs and public agencies.

Estimates by "experts," based on their perceptions of abortion's prevalence in a given area.

The frequency with which WHO lists "experts' estimates" as data sources is especially disturbing. Even when researchers have some hard data, these statistics are adjusted and extrapolated multiple times based on such things as assumptions about the frequency of miscarriage and abortion complications and the degree of the always-presumed underreporting. WHO cites very little supporting data for these assumptions. This is a concern because the particular multiplier that researchers choose for adjusting their data could affect their estimates of worldwide abortions by many millions. (See "From the Groundless to the Ridiculous," p.xxx.)

ABORTION POLICIES AND MATERNAL MORTALITY

A second problem with the argument that broadly legal abortion will cure high levels of "unsafe" abortion and maternal mortality is that the legalization of abortion does nothing to solve the underlying problem of poor health care in the developing world. In the United States, the world's leader in modern medicine, the Centers for Disease Control and Prevention reports that over 300 women have died from legal abortions since the procedure was legalized nationwide in 1973. Even under the best medical conditions, an experienced abortionist may puncture a uterus, bowel, or bladder, leading to hemorrhage, infection, and possibly death. Under the sort of circumstances prevailing in the developing world, where conditions may not always be fully sanitary, where emergency facilities and supplies are absent or inadequate, where doctors may not be trained or equipped to handle trauma, and where even basic medical and surgical supplies such as antibiotics and sterile gloves may be scarce or unavailable, mortality rates would be expected to be substantially higher, whether abortion is legal or not.

Legalization would very likely increase women's exposure to these health risks. Evidence indicates that the liberalization of abortion laws increases the number of abortions. Stanley Henshaw, lead researcher for AGI, has admitted, "In most countries, it is common after abortion is legalized for abortion rates to rise sharply for several years, then stabilize, just as we have seen in the United States." The Population Division's report notes several countries in which abortions rose rapidly after the law's liberalization.

Women generally at risk because they lack access to a doctor, hospital, or antibiotics before abortion's legalization will face those same circumstances after legalization. And if legalization triggers a higher demand for abortion, as it has in most countries, more injured women will compete for those scarce medical resources.

UN publications provide several examples in which legal abortion and lower maternal mortality rates do not coincide. Consider Britain, where abortion has been broadly legal for decades, and the nearby Republic of Ireland, which has long banned the practice. According to the 1990 UN Demographic Handbook, Ireland's maternal mortality rate for 1988 was some three and a half times lower than Britain's. Abortion Policies: A Global Review notes that, despite the recent expansion of India's laws to allow abortion for social and economic reasons, the procedure is still practiced under dangerous conditions and the maternal mortality rate remains high. In Paraguay, in contrast, the Population Division comments that maternal mortality rates have been declining, even though abortion is generally prohibited and "clandestine abortion is common."

Despite these facts, arguments about high levels of "unsafe" abortions and the need to legalize abortion to decrease maternal mortality still dominate the international abortion debate. Yet the facts suggest that maternal mortality can be reduced in the developing world the same way it has been done in the developed world since 1941--by improving basic and maternal health care and the general health status of women, not by legalizing abortion.